Bronson South Haven Hospital

All Charges

Charge

Type

Setting

Price

PR LAPS CLSR NTRSTM LG/SM INT W/RESCJ & ANASTOMOSIS

Professional

Both

$3,833.00

Service Code	HCPCS 44227
Min. Negotiated Rate	$1,055.63
Max. Negotiated Rate	$2,945.38
Rate for Payer: Aetna Commercial	$2,238.05
Rate for Payer: Aetna Medicare	$1,916.50
Rate for Payer: BCBS Complete	$1,108.41
Rate for Payer: BCBS Trust/PPO	$1,489.81
Rate for Payer: BCN Commercial	$2,405.27
Rate for Payer: Cash Price	$3,066.40
Rate for Payer: Cash Price	$3,066.40
Rate for Payer: Meridian Medicaid	$1,108.41
Rate for Payer: Priority Health Choice Medicaid	$1,055.63
Rate for Payer: Priority Health Cigna Priority Health	$2,491.45
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,945.38
Rate for Payer: Priority Health Narrow Network	$2,945.38
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,029.44
Rate for Payer: UHC Exchange	$2,029.44
Rate for Payer: UHCCP Medicaid	$1,055.63

PR LAPS COLCT TTL ABD W/PRCTECT ILEOANAL ANASTOMSIS

Professional

Both

$6,309.00

Service Code	HCPCS 44211
Min. Negotiated Rate	$1,339.56
Max. Negotiated Rate	$4,100.85
Rate for Payer: Aetna Commercial	$2,816.64
Rate for Payer: Aetna Medicare	$3,154.50
Rate for Payer: BCBS Complete	$1,406.54
Rate for Payer: BCBS Trust/PPO	$1,775.09
Rate for Payer: BCN Commercial	$3,053.75
Rate for Payer: Cash Price	$5,047.20
Rate for Payer: Cash Price	$5,047.20
Rate for Payer: Meridian Medicaid	$1,406.54
Rate for Payer: Priority Health Choice Medicaid	$1,339.56
Rate for Payer: Priority Health Cigna Priority Health	$4,100.85
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,740.65
Rate for Payer: Priority Health Narrow Network	$3,740.65
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,693.49
Rate for Payer: UHC Exchange	$2,693.49
Rate for Payer: UHCCP Medicaid	$1,339.56

PR LAPS COLECTMY PRTL W/COLOPXTSTMY LW ANAST W/CLST

Professional

Both

$4,661.00

Service Code	HCPCS 44208
Min. Negotiated Rate	$1,250.95
Max. Negotiated Rate	$3,497.23
Rate for Payer: Aetna Commercial	$2,648.24
Rate for Payer: Aetna Medicare	$2,330.50
Rate for Payer: BCBS Complete	$1,313.50
Rate for Payer: BCBS Trust/PPO	$1,882.86
Rate for Payer: BCN Commercial	$2,853.87
Rate for Payer: Cash Price	$3,728.80
Rate for Payer: Cash Price	$3,728.80
Rate for Payer: Meridian Medicaid	$1,313.50
Rate for Payer: Priority Health Choice Medicaid	$1,250.95
Rate for Payer: Priority Health Cigna Priority Health	$3,029.65
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,497.23
Rate for Payer: Priority Health Narrow Network	$3,497.23
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,414.03
Rate for Payer: UHC Exchange	$2,414.03
Rate for Payer: UHCCP Medicaid	$1,250.95

PR LAPS COLECTOMY ABDL W/PROCTECTOMY W/ILEOSTOMY

Professional

Both

$6,262.00

Service Code	HCPCS 44212
Min. Negotiated Rate	$994.79
Max. Negotiated Rate	$4,070.30
Rate for Payer: Aetna Commercial	$2,718.21
Rate for Payer: Aetna Medicare	$3,131.00
Rate for Payer: BCBS Complete	$1,353.53
Rate for Payer: BCBS Trust/PPO	$994.79
Rate for Payer: BCN Commercial	$2,925.71
Rate for Payer: Cash Price	$5,009.60
Rate for Payer: Cash Price	$5,009.60
Rate for Payer: Meridian Medicaid	$1,353.53
Rate for Payer: Priority Health Choice Medicaid	$1,289.08
Rate for Payer: Priority Health Cigna Priority Health	$4,070.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,587.32
Rate for Payer: Priority Health Narrow Network	$3,587.32
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,488.10
Rate for Payer: UHC Exchange	$2,488.10
Rate for Payer: UHCCP Medicaid	$1,289.08

PR LAPS COLECTOMY PRTL W/COLOPXTSTMY LW ANAST

Professional

Both

$4,592.00

Service Code	HCPCS 44207
Min. Negotiated Rate	$1,150.84
Max. Negotiated Rate	$3,212.06
Rate for Payer: Aetna Commercial	$2,434.39
Rate for Payer: Aetna Medicare	$2,296.00
Rate for Payer: BCBS Complete	$1,208.38
Rate for Payer: BCBS Trust/PPO	$1,992.75
Rate for Payer: BCN Commercial	$2,621.76
Rate for Payer: Cash Price	$3,673.60
Rate for Payer: Cash Price	$3,673.60
Rate for Payer: Meridian Medicaid	$1,208.38
Rate for Payer: Priority Health Choice Medicaid	$1,150.84
Rate for Payer: Priority Health Cigna Priority Health	$2,984.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,212.06
Rate for Payer: Priority Health Narrow Network	$3,212.06
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,226.38
Rate for Payer: UHC Exchange	$2,226.38
Rate for Payer: UHCCP Medicaid	$1,150.84

PR LAPS COLECTOMY PRTL W/END CLST & CLSR DSTL SGM

Professional

Both

$4,736.00

Service Code	HCPCS 44206
Min. Negotiated Rate	$1,107.39
Max. Negotiated Rate	$3,095.14
Rate for Payer: Aetna Commercial	$2,349.86
Rate for Payer: Aetna Medicare	$2,368.00
Rate for Payer: BCBS Complete	$1,162.76
Rate for Payer: BCBS Trust/PPO	$1,931.99
Rate for Payer: BCN Commercial	$2,525.48
Rate for Payer: Cash Price	$3,788.80
Rate for Payer: Cash Price	$3,788.80
Rate for Payer: Meridian Medicaid	$1,162.76
Rate for Payer: Priority Health Choice Medicaid	$1,107.39
Rate for Payer: Priority Health Cigna Priority Health	$3,078.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,095.14
Rate for Payer: Priority Health Narrow Network	$3,095.14
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,128.15
Rate for Payer: UHC Exchange	$2,128.15
Rate for Payer: UHCCP Medicaid	$1,107.39

PR LAPS COLECTOMY PRTL W/RMVL TERMINAL ILEUM

Professional

Both

$4,199.00

Service Code	HCPCS 44205
Min. Negotiated Rate	$850.94
Max. Negotiated Rate	$2,729.35
Rate for Payer: Aetna Commercial	$1,793.71
Rate for Payer: Aetna Medicare	$2,099.50
Rate for Payer: BCBS Complete	$893.49
Rate for Payer: BCBS Trust/PPO	$1,868.07
Rate for Payer: BCN Commercial	$1,936.14
Rate for Payer: Cash Price	$3,359.20
Rate for Payer: Cash Price	$3,359.20
Rate for Payer: Meridian Medicaid	$893.49
Rate for Payer: Priority Health Choice Medicaid	$850.94
Rate for Payer: Priority Health Cigna Priority Health	$2,729.35
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,372.06
Rate for Payer: Priority Health Narrow Network	$2,372.06
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,627.39
Rate for Payer: UHC Exchange	$1,627.39
Rate for Payer: UHCCP Medicaid	$850.94

PR LAPS COLECTOMY TOT W/O PRCTECT W/ILEOST/ILEOPXTS

Professional

Both

$5,282.00

Service Code	HCPCS 44210
Min. Negotiated Rate	$1,124.43
Max. Negotiated Rate	$3,433.30
Rate for Payer: Aetna Commercial	$2,365.94
Rate for Payer: Aetna Medicare	$2,641.00
Rate for Payer: BCBS Complete	$1,180.65
Rate for Payer: BCBS Trust/PPO	$1,790.41
Rate for Payer: BCN Commercial	$2,564.09
Rate for Payer: Cash Price	$4,225.60
Rate for Payer: Cash Price	$4,225.60
Rate for Payer: Meridian Medicaid	$1,180.65
Rate for Payer: Priority Health Choice Medicaid	$1,124.43
Rate for Payer: Priority Health Cigna Priority Health	$3,433.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,141.66
Rate for Payer: Priority Health Narrow Network	$3,141.66
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,167.58
Rate for Payer: UHC Exchange	$2,167.58
Rate for Payer: UHCCP Medicaid	$1,124.43

PR LAPS ENTERECT RESCJ 1 SMALL INTEST RESCJ & ANA

Facility

$4,652.00

Service Code	CPT 44202
Hospital Charge Code	44202
Min. Negotiated Rate	$1,860.80
Max. Negotiated Rate	$4,652.00
Rate for Payer: Aetna Commercial	$4,186.80
Rate for Payer: Aetna Medicare	$2,326.00
Rate for Payer: ASR ASR	$4,512.44
Rate for Payer: ASR Commercial	$4,512.44
Rate for Payer: BCBS Complete	$1,860.80
Rate for Payer: BCBS Trust/PPO	$3,809.52
Rate for Payer: BCN Commercial	$3,606.70
Rate for Payer: Cash Price	$3,721.60
Rate for Payer: Cofinity Commercial	$4,372.88
Rate for Payer: Encore Health Key Benefits Commercial	$3,721.60
Rate for Payer: Healthscope Commercial	$4,652.00
Rate for Payer: Healthscope Whirlpool	$4,512.44
Rate for Payer: Mclaren Commercial	$4,186.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,954.20
Rate for Payer: Nomi Health Commercial	$3,814.64
Rate for Payer: Priority Health Cigna Priority Health	$3,023.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$4,076.08
Rate for Payer: Priority Health Narrow Network	$3,261.05
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,093.76

PR LAPS ENTERECT RESCJ 1 SMALL INTEST RESCJ & ANA

Professional

Both

$4,652.00

Service Code	HCPCS 44202
Hospital Charge Code	44202
Min. Negotiated Rate	$764.98
Max. Negotiated Rate	$3,023.80
Rate for Payer: Aetna Commercial	$1,868.47
Rate for Payer: Aetna Medicare	$2,326.00
Rate for Payer: BCBS Complete	$932.84
Rate for Payer: BCBS Trust/PPO	$764.98
Rate for Payer: BCN Commercial	$2,019.70
Rate for Payer: Cash Price	$3,721.60
Rate for Payer: Cash Price	$3,721.60
Rate for Payer: Meridian Medicaid	$932.84
Rate for Payer: Priority Health Choice Medicaid	$888.42
Rate for Payer: Priority Health Cigna Priority Health	$3,023.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,475.86
Rate for Payer: Priority Health Narrow Network	$2,475.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,678.78
Rate for Payer: UHC Exchange	$1,678.78
Rate for Payer: UHCCP Medicaid	$888.42

PR LAPS ENTERECT RESCJ 1 SMALL INTEST RESCJ & ANA

Professional

Both

$4,652.00

Service Code	HCPCS 44202
Min. Negotiated Rate	$764.98
Max. Negotiated Rate	$3,023.80
Rate for Payer: Aetna Commercial	$1,868.47
Rate for Payer: Aetna Medicare	$2,326.00
Rate for Payer: BCBS Complete	$932.84
Rate for Payer: BCBS Trust/PPO	$764.98
Rate for Payer: BCN Commercial	$2,019.70
Rate for Payer: Cash Price	$3,721.60
Rate for Payer: Cash Price	$3,721.60
Rate for Payer: Meridian Medicaid	$932.84
Rate for Payer: Priority Health Choice Medicaid	$888.42
Rate for Payer: Priority Health Cigna Priority Health	$3,023.80
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,475.86
Rate for Payer: Priority Health Narrow Network	$2,475.86
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,678.78
Rate for Payer: UHC Exchange	$1,678.78
Rate for Payer: UHCCP Medicaid	$888.42

PR LAPS ENTERECT RESCJ 1 SMALL INTEST RESCJ & ANA

Facility

$4,652.00

Service Code	CPT 44202
Hospital Charge Code	44202
Min. Negotiated Rate	$3,023.80
Max. Negotiated Rate	$4,652.00
Rate for Payer: Aetna Commercial	$4,186.80
Rate for Payer: ASR ASR	$4,512.44
Rate for Payer: ASR Commercial	$4,512.44
Rate for Payer: BCBS Trust/PPO	$3,790.91
Rate for Payer: BCN Commercial	$3,606.70
Rate for Payer: Cash Price	$3,721.60
Rate for Payer: Cofinity Commercial	$4,372.88
Rate for Payer: Encore Health Key Benefits Commercial	$3,721.60
Rate for Payer: Healthscope Commercial	$4,652.00
Rate for Payer: Healthscope Whirlpool	$4,512.44
Rate for Payer: Mclaren Commercial	$4,186.80
Rate for Payer: Multiplan/Beech St/PHCS Commercial	$3,954.20
Rate for Payer: Nomi Health Commercial	$3,814.64
Rate for Payer: Priority Health Cigna Priority Health	$3,023.80
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$4,093.76

PR LAPS ESOPHAGEAL LENGTHENING ADDL

Professional

Both

$294.00

Service Code	HCPCS 43283
Min. Negotiated Rate	$99.47
Max. Negotiated Rate	$868.53
Rate for Payer: Aetna Commercial	$214.16
Rate for Payer: Aetna Medicare	$147.00
Rate for Payer: BCBS Complete	$104.44
Rate for Payer: BCBS Trust/PPO	$868.53
Rate for Payer: BCN Commercial	$227.24
Rate for Payer: Cash Price	$235.20
Rate for Payer: Cash Price	$235.20
Rate for Payer: Meridian Medicaid	$104.44
Rate for Payer: Priority Health Choice Medicaid	$99.47
Rate for Payer: Priority Health Cigna Priority Health	$191.10
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$278.60
Rate for Payer: Priority Health Narrow Network	$278.60
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$222.68
Rate for Payer: UHC Exchange	$222.68
Rate for Payer: UHCCP Medicaid	$99.47

PR LAPS ESOPHAGOMYOTOMY W/FUNDOPLASTY IF PERFORMED

Professional

Both

$2,403.00

Service Code	HCPCS 43279
Min. Negotiated Rate	$777.66
Max. Negotiated Rate	$2,289.72
Rate for Payer: Aetna Commercial	$1,737.87
Rate for Payer: Aetna Medicare	$1,201.50
Rate for Payer: BCBS Complete	$861.94
Rate for Payer: BCBS Trust/PPO	$777.66
Rate for Payer: BCN Commercial	$1,866.26
Rate for Payer: Cash Price	$1,922.40
Rate for Payer: Cash Price	$1,922.40
Rate for Payer: Meridian Medicaid	$861.94
Rate for Payer: Priority Health Choice Medicaid	$820.90
Rate for Payer: Priority Health Cigna Priority Health	$1,561.95
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$2,289.72
Rate for Payer: Priority Health Narrow Network	$2,289.72
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,580.63
Rate for Payer: UHC Exchange	$1,580.63
Rate for Payer: UHCCP Medicaid	$820.90

PR LAPS FULG/EXC OVARY VISCERA/PERITONEAL SURFACE

Professional

Both

$2,228.00

Service Code	HCPCS 58662
Min. Negotiated Rate	$237.21
Max. Negotiated Rate	$1,448.20
Rate for Payer: Aetna Commercial	$851.14
Rate for Payer: Aetna Medicare	$1,114.00
Rate for Payer: BCBS Complete	$480.85
Rate for Payer: BCBS Trust/PPO	$237.21
Rate for Payer: BCN Commercial	$1,043.33
Rate for Payer: Cash Price	$1,782.40
Rate for Payer: Cash Price	$1,782.40
Rate for Payer: Meridian Medicaid	$480.85
Rate for Payer: Priority Health Choice Medicaid	$457.95
Rate for Payer: Priority Health Cigna Priority Health	$1,448.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,066.99
Rate for Payer: Priority Health Narrow Network	$1,066.99
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$806.92
Rate for Payer: UHC Exchange	$806.92
Rate for Payer: UHCCP Medicaid	$457.95

PR LAPS GASTRIC RESTRICTIVE PX REMOVE DEVICE & PORT

Professional

Both

$1,726.00

Service Code	HCPCS 43774
Min. Negotiated Rate	$530.94
Max. Negotiated Rate	$1,724.16
Rate for Payer: Aetna Commercial	$1,298.33
Rate for Payer: Aetna Medicare	$863.00
Rate for Payer: BCBS Complete	$650.82
Rate for Payer: BCBS Trust/PPO	$530.94
Rate for Payer: BCN Commercial	$1,404.95
Rate for Payer: Cash Price	$1,380.80
Rate for Payer: Cash Price	$1,380.80
Rate for Payer: Meridian Medicaid	$650.82
Rate for Payer: Priority Health Choice Medicaid	$619.83
Rate for Payer: Priority Health Cigna Priority Health	$1,121.90
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,724.16
Rate for Payer: Priority Health Narrow Network	$1,724.16
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,158.74
Rate for Payer: UHC Exchange	$1,158.74
Rate for Payer: UHCCP Medicaid	$619.83

PR LAPS GSTRC RSTRICTIV PX LONGITUDINAL GASTRECTOMY

Professional

Both

$4,667.00

Service Code	HCPCS 43775
Min. Negotiated Rate	$706.52
Max. Negotiated Rate	$3,033.55
Rate for Payer: Aetna Commercial	$1,509.61
Rate for Payer: Aetna Medicare	$2,333.50
Rate for Payer: BCBS Complete	$741.85
Rate for Payer: BCBS Trust/PPO	$1,269.50
Rate for Payer: BCN Commercial	$1,611.66
Rate for Payer: Cash Price	$3,733.60
Rate for Payer: Cash Price	$3,733.60
Rate for Payer: Meridian Medicaid	$741.85
Rate for Payer: Priority Health Choice Medicaid	$706.52
Rate for Payer: Priority Health Cigna Priority Health	$3,033.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,970.56
Rate for Payer: Priority Health Narrow Network	$1,970.56
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,650.63
Rate for Payer: UHC Exchange	$1,650.63
Rate for Payer: UHCCP Medicaid	$706.52

PR LAPS GSTR RSTCV PX W/BYP ROUX-EN-Y LIMB <150 CM

Professional

Both

$3,090.00

Service Code	HCPCS 43644
Min. Negotiated Rate	$916.07
Max. Negotiated Rate	$3,107.67
Rate for Payer: Aetna Commercial	$2,348.37
Rate for Payer: Aetna Medicare	$1,545.00
Rate for Payer: BCBS Complete	$1,170.81
Rate for Payer: BCBS Trust/PPO	$916.07
Rate for Payer: BCN Commercial	$2,532.82
Rate for Payer: Cash Price	$2,472.00
Rate for Payer: Cash Price	$2,472.00
Rate for Payer: Meridian Medicaid	$1,170.81
Rate for Payer: Priority Health Choice Medicaid	$1,115.06
Rate for Payer: Priority Health Cigna Priority Health	$2,008.50
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,107.67
Rate for Payer: Priority Health Narrow Network	$3,107.67
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,103.75
Rate for Payer: UHC Exchange	$2,103.75
Rate for Payer: UHCCP Medicaid	$1,115.06

PR LAPS GSTR RSTCV PX W/BYP&SM INT RCNSTJ

Professional

Both

$3,336.00

Service Code	HCPCS 43645
Min. Negotiated Rate	$1,018.03
Max. Negotiated Rate	$3,301.55
Rate for Payer: Aetna Commercial	$2,485.52
Rate for Payer: Aetna Medicare	$1,668.00
Rate for Payer: BCBS Complete	$1,248.19
Rate for Payer: BCBS Trust/PPO	$1,018.03
Rate for Payer: BCN Commercial	$2,690.66
Rate for Payer: Cash Price	$2,668.80
Rate for Payer: Cash Price	$2,668.80
Rate for Payer: Meridian Medicaid	$1,248.19
Rate for Payer: Priority Health Choice Medicaid	$1,188.75
Rate for Payer: Priority Health Cigna Priority Health	$2,168.40
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,301.55
Rate for Payer: Priority Health Narrow Network	$3,301.55
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,249.71
Rate for Payer: UHC Exchange	$2,249.71
Rate for Payer: UHCCP Medicaid	$1,188.75

PR LAPS INSERTION TUNNELED INTRAPERITONEAL CATHETER

Professional

Both

$742.00

Service Code	HCPCS 49324
Min. Negotiated Rate	$248.36
Max. Negotiated Rate	$2,137.50
Rate for Payer: Aetna Commercial	$524.84
Rate for Payer: Aetna Medicare	$371.00
Rate for Payer: BCBS Complete	$260.78
Rate for Payer: BCBS Trust/PPO	$2,137.50
Rate for Payer: BCN Commercial	$565.89
Rate for Payer: Cash Price	$593.60
Rate for Payer: Cash Price	$593.60
Rate for Payer: Meridian Medicaid	$260.78
Rate for Payer: Priority Health Choice Medicaid	$248.36
Rate for Payer: Priority Health Cigna Priority Health	$482.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$693.83
Rate for Payer: Priority Health Narrow Network	$693.83
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$476.34
Rate for Payer: UHC Exchange	$476.34
Rate for Payer: UHCCP Medicaid	$248.36

PR LAPS LIGATION SPERMATIC VEINS VARICOCELE

Professional

Both

$887.00

Service Code	HCPCS 55550
Min. Negotiated Rate	$277.11
Max. Negotiated Rate	$2,149.12
Rate for Payer: Aetna Commercial	$549.39
Rate for Payer: Aetna Medicare	$443.50
Rate for Payer: BCBS Complete	$290.97
Rate for Payer: BCBS Trust/PPO	$2,149.12
Rate for Payer: BCN Commercial	$622.09
Rate for Payer: Cash Price	$709.60
Rate for Payer: Cash Price	$709.60
Rate for Payer: Meridian Medicaid	$290.97
Rate for Payer: Priority Health Choice Medicaid	$277.11
Rate for Payer: Priority Health Cigna Priority Health	$576.55
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$688.66
Rate for Payer: Priority Health Narrow Network	$688.66
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$506.17
Rate for Payer: UHC Exchange	$506.17
Rate for Payer: UHCCP Medicaid	$277.11

PR LAPS MOBLJ SPLENIC FLXR PFRMD W/PRTL COLECTOMY

Professional

Both

$518.00

Service Code	HCPCS 44213
Min. Negotiated Rate	$118.00
Max. Negotiated Rate	$1,274.26
Rate for Payer: Aetna Commercial	$252.05
Rate for Payer: Aetna Medicare	$259.00
Rate for Payer: BCBS Complete	$123.90
Rate for Payer: BCBS Trust/PPO	$1,274.26
Rate for Payer: BCN Commercial	$268.29
Rate for Payer: Cash Price	$414.40
Rate for Payer: Cash Price	$414.40
Rate for Payer: Meridian Medicaid	$123.90
Rate for Payer: Priority Health Choice Medicaid	$118.00
Rate for Payer: Priority Health Cigna Priority Health	$336.70
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$328.72
Rate for Payer: Priority Health Narrow Network	$328.72
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$234.11
Rate for Payer: UHC Exchange	$234.11
Rate for Payer: UHCCP Medicaid	$118.00

PR LAPS MYOMECTOMY EXC 1-4 MYOMAS 250 GM/<

Professional

Both

$1,908.00

Service Code	HCPCS 58545
Min. Negotiated Rate	$459.62
Max. Negotiated Rate	$1,348.76
Rate for Payer: Aetna Commercial	$1,078.67
Rate for Payer: Aetna Medicare	$954.00
Rate for Payer: BCBS Complete	$607.22
Rate for Payer: BCBS Trust/PPO	$459.62
Rate for Payer: BCN Commercial	$1,320.41
Rate for Payer: Cash Price	$1,526.40
Rate for Payer: Cash Price	$1,526.40
Rate for Payer: Meridian Medicaid	$607.22
Rate for Payer: Priority Health Choice Medicaid	$578.30
Rate for Payer: Priority Health Cigna Priority Health	$1,240.20
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,348.76
Rate for Payer: Priority Health Narrow Network	$1,348.76
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,024.74
Rate for Payer: UHC Exchange	$1,024.74
Rate for Payer: UHCCP Medicaid	$578.30

PR LAPS MYOMECTOMY EXC 5/> MYOMAS >250 GRAMS

Professional

Both

$2,402.00

Service Code	HCPCS 58546
Min. Negotiated Rate	$74.49
Max. Negotiated Rate	$1,661.75
Rate for Payer: Aetna Commercial	$1,338.60
Rate for Payer: Aetna Medicare	$1,201.00
Rate for Payer: BCBS Complete	$748.34
Rate for Payer: BCBS Trust/PPO	$74.49
Rate for Payer: BCN Commercial	$1,631.21
Rate for Payer: Cash Price	$1,921.60
Rate for Payer: Cash Price	$1,921.60
Rate for Payer: Meridian Medicaid	$748.34
Rate for Payer: Priority Health Choice Medicaid	$712.70
Rate for Payer: Priority Health Cigna Priority Health	$1,561.30
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$1,661.75
Rate for Payer: Priority Health Narrow Network	$1,661.75
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$1,296.02
Rate for Payer: UHC Exchange	$1,296.02
Rate for Payer: UHCCP Medicaid	$712.70

PR LAPS PROCTECTOMY ABDOMINOPERINEAL W/COLOSTOMY

Professional

Both

$5,631.00

Service Code	HCPCS 45395
Min. Negotiated Rate	$75.55
Max. Negotiated Rate	$3,660.15
Rate for Payer: Aetna Commercial	$2,624.03
Rate for Payer: Aetna Medicare	$2,815.50
Rate for Payer: BCBS Complete	$1,303.88
Rate for Payer: BCBS Trust/PPO	$75.55
Rate for Payer: BCN Commercial	$2,834.82
Rate for Payer: Cash Price	$4,504.80
Rate for Payer: Cash Price	$4,504.80
Rate for Payer: Meridian Medicaid	$1,303.88
Rate for Payer: Priority Health Choice Medicaid	$1,241.79
Rate for Payer: Priority Health Cigna Priority Health	$3,660.15
Rate for Payer: Priority Health HMO/PPO/Tiered Network	$3,472.17
Rate for Payer: Priority Health Narrow Network	$3,472.17
Rate for Payer: UHC All Payor (Choice/PPO) + Core	$2,398.64
Rate for Payer: UHC Exchange	$2,398.64
Rate for Payer: UHCCP Medicaid	$1,241.79

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